Lateral elbow ligament reconstruction for posterolateral rotatory instability: 10 years follow-up in 32 patients.

Background: Posterolateral rotatory instability (PLRI) is the most frequent form of both acute and chronic elbow instability. It is due to mechanical incompetence of the lateral collateral ligament. O'Driscoll et al described treatment of this instability by autologous reconstruction of the lateral ulnar collateral ligament. The aim of our study was to evaluate the medium and long-term clinical, functional and radiological results of patients who were surgically treated for PLRI by this technique. We hypothesized that such ligament reconstruction restores a functional joint complex and durably stabilizes the elbow and limits the long-term risk of osteoarthritis. Methods: All patients treated for symptomatic PLRI by ligament reconstruction since January 1995 and who had a minimum follow-up of 36 months were retrospectively included. Results: Thirty-two patients (32 elbows) underwent clinical and radiological evaluation with a mean follow-up of 112 months (range, 36-265 months). The success rate of the procedure was 97% with one patient requiring revision reconstruction. Twenty-four patients (75%) were free from pain. Pain was significantly greater in patients with associated lesions (P = .03) and those with morbid obesity (body mass index ≥40) (P = .03). Twenty-nine (91%) patients had resumed their previous activities. Twenty-eight patients (87%) were satisfied or very satisfied. The mean Mayo Clinic score was 96/100 and the QuickDash 14.7/100. Two patients (6%) with accompanying lesions developed severe osteoarthritis. Conclusion: Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. The only failure in our series was due to several technical errors. Patients who had dislocation with associated lesions or morbid obesity are at risk of poorer functional results.

Posterolateral stabilization of the elbow by autologous ligament reconstruction to limit long-term development of osteoarthritis.

BACKGROUND: Posterolateral instability is the most frequent form of both acute and chronic elbow instability. Joint incongruity due to posterolateral unlocking leads to shear and compression stress of the internal aspect of the humeroulnar joint. We carried out long-term analysis of patients with posterolateral elbow instability in order to determine whether, in addition to improving their symptoms, reconstruction of the lateral collateral ligament complex may play a protective role against the development of post-traumatic osteoarthritis. We hypothesized that ligament reconstruction according to the technique of O'Driscoll stabilizes the elbow and also limits the development of osteoarthritis in the long term. METHODS: Patients with symptomatic posterolateral instability of the elbow and who underwent ligament reconstruction according to the technique of O'Driscoll from January 1995 to December 2010 were identified and retrospectively included for 2 follow-up evaluations at a mean of 5 and 14 years. RESULTS: Fourteen elbows in 14 patients were included. All had a negative lateral pivot shift test and none reported a new episode of instability. Two patients (14%) had osteoarthritis. The 2 radiographic evaluations showed no progression of osteoarthritis. Osteoarthritis developed in 33% of patients with intra-articular fracture. In simple dislocations, pre-existing osteoarthritic lesions were stabilized and there were no new cases of osteoarthritis. CONCLUSION: Elbow ligament reconstruction according to the technique of O'Driscoll gives effective posterolateral stabilization and appears to protect against progression to osteoarthritic degeneration in the long term. In the absence of associated lesions, it prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis.

Management of chronic mallet finger: Indications and long-term results of Fowler central slip tenotomy and distal interphalangeal joint arthrodesis.

INTRODUCTION: Many surgical techniques have been described to correct the sequelae of chronic mallet fingers (MF), but no clear therapeutic strategy has been defined. We have reported the choice of their management according to the severity of the deformities. Two procedures were compared: Fowler's central slip tenotomy (CST) and arthrodesis of the distal interphalangeal joint (DIP). HYPOTHESIS: The use of our decision tree, based on the severity of deformity (flexion deformity at the DIP and recurvatum at the proximal interphalangeal joint), allows good long-term clinical results to be obtained. MATERIAL AND METHODS: Thirty-three patients (34 fingers) were operated on for sequelae of chronic MF either by CST or by DIP arthrodesis. Patients with ≤35° DIP flexion deformity and <25° proximal interphalangeal (PIP) recurvatum, without DIP joint involvement (osteoarthritis, subluxation, stiffness), were treated with CST. For the others, arthrodesis of the DIP joint was performed. RESULTS: Thirteen patients (13 fingers) were evaluated in the CST group with a mean follow-up of 13 years. There were no postoperative complications and no failures. The mean DIP residual extension lag was 4.23° with complete correction of the PIP recurvatum. All patients would redo the intervention in hindsight. The improvement in Quick-DASH was statistically significant (p=0.01). Twenty patients (21 fingers) were included in the DIP arthrodesis group with a mean follow-up of 10 years. Two failures (9.5%) occurred due to failed correction of the PIP recurvatum. No worsening of the deformities was reported, and they were corrected in 90% of cases. The absence of correction of the PIP recurvatum was more frequent in MF bone (p=0.01). All except 1 (95%) patient, who reported a lack of mobility of the DIP joint, would repeat the procedure. Quick-DASH was improved for all patients. DISCUSSION: CST is effective in correcting deformities in chronic MFs for ≤35° DIP flexion deformity and <25° PIP recurvatum without DIP joint involvement. In other cases, it is preferable to perform a DIP arthrodesis by combining, if necessary, a complementary procedure to correct the PIP recurvatum. LEVEL OF EVIDENCE: IV, retrospective study.

Total arthrodesis for non-rheumatoid wrists: Outcomes at 5 and 20years of follow-up.

INTRODUCTION: Total wrist arthrodesis (TWA) aims to obtain a painless wrist with a strong grip. Its main disadvantage is compromised mobility and for many authors it remains a rescue intervention. However, after one or more palliative interventions, TWA confers poorer results. The objective of our study was to evaluate the medium-term results of TWA, and their long-term stability. HYPOTHESIS: Our hypothesis was that the results are reliable and persistent for pain and strength, without repercussions to other joints. MATERIAL AND METHODS: This was a single-center consecutive series of TWA performed with a dedicated plate, excluding rheumatoid wrists, evaluated at 5.4 and 21.1years of follow-up. RESULTS: Thirty wrists were assessed at the first review and 17 reassessed at the last follow-up. At the mean follow-up of 5.4years, 93% of patients considered themselves "very satisfied" or "satisfied" with the TWA surgery. No infectious complications occurred. At the mean follow-up of 21.1years, all were "very satisfied" or "satisfied" and 88% of them considered their result stable or improved compared to the first revision. The average VAS had gone from 8.4/10 preoperatively to 1.8/10 at the first evaluation and to 0.3/10 at the last follow-up. Except for a patient with both wrists operated on for whom comparison was not possible, the strength of the operated side was on average 89.7% of that of the contralateral side (from 45% to 150%). The mean Quick DASH score was 30.3 (4.5 to 61.4) and the mean PRWE score was 32.5 (1 to 77). DISCUSSION: TWA using a plate provides excellent results for both pain control and strength restoration. The clinical results remain stable over time, and arthrodesis at more than 20years of follow-up does not seem to have any impact on the other joints of the upper limb. After wrist surgery, the main complaint of patients is the limited range of motion, but the main cause of dissatisfaction is persistent pain. Arthrodesis can be performed first-line in case of questionable indication of partial arthrodesis on a stiff wrist because the results of TWA are better in the absence of a surgical history. LEVEL OF EVIDENCE: IV; retrospective study.

Long-term outcomes of coracoid bone block osteolysis: case report.

Latarjet procedure is reliable and reproductible procedure for treatment of anterior shoulder instability. Results are durable but complications can occur: neurological injury, non-union, infection, stiffness, osteolysis of coracoid bone block, recurrence of dislocation, osteoarthritis. We present the case of two patients with complication not described in the literature: osteolysis of the neck of the scapula around screws discovered at 8 and 20 years after initial surgery. These patients presented with previous pain which motivated consultation. Imaging showed coracoid bone block osteolysis, extensive geode weakening articular surface of scapular glenoid, around screws which are not bi-cortical. Screws were removed, osteolysis was filled with iliac cancellous bone graft and joint capsule was re-tensioned. Results of this procedure at one year were clinical and radiological satisfactory.

Scapular winging due to rhomboid muscle paralysis: clinical assessment of 4 cases and anatomic study of the dorsal scapular nerve.

BACKGROUND: A rare cause of scapular winging is rhomboid muscle paralysis secondary to dorsal scapular nerve (DSN) neuropathy. This paralysis causes winging of the medial border of the scapula with lateral rotation of its inferior angle. We report a series of 4 clinical cases of isolated DSN compression and the results of a specific rehabilitation protocol. METHODS: A continuous clinical series of 4 patients with isolated rhomboid muscle deficiency was analyzed. Two patients were men and 2 were women, with a mean age of 40 years (range, 33-51 years). Three patients were right-handed and 1 was left-handed. Scapular winging always affected the dominant side. Two patients had occupations involving heavy physical work. The sports practiced involved exertion of the arms (dancing, boxing, gymnastics, muscle strengthening). A specific rehabilitation protocol was offered to the patients. In addition, 6 fresh cadaver dissections were performed to reveal possible DSN compression. Potential areas of compression were identified, in particular when the arm was raised. RESULTS: The 4 patients presented with isolated DSN neuropathy were confirmed by electroneuromyographic testing. Total correction of scapular winging was not obtained in any patient. Three patients experienced residual pain with a neuropathic pain by the questionnaire for a Diagnosis of Neuropathic Pain (DN4) score of 2. The mean Quick-Disabilities of the Arm, Shoulder and Hand (DASH) score after treatment was 31.8 of 100. The mean ASES score was 56.2. Only 1 patient agreed to rehabilitation in a specialized center and underwent follow-up electroneuromyography. Signs of rhomboid muscle denervation were no longer present and distal motor latencies had become normal. In all cadaver dissections, the DSN originated from the C5 nerve root and did not pass through the middle scalene muscle. We identified a site of dynamic compression of the DSN by the upper part of the medial border of the scapula when the arm was raised. DISCUSSION: DSN compression is conventionally attributed to the middle scalene muscle, but it is noteworthy that our study reveals the possibility of dynamic compression of the nerve by the proximal part of the medial border of the scapula, which occurs when the arm elevation is above 90°. CONCLUSION: Our study reveals the possibility of dynamic compression of the DSN by the proximal part of the medial border of the scapula, which occurs when the arm is raised above 90°. In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team.

Outcomes of 53 thoracic outlet syndrome cases with confirmed neurological deficit.

INTRODUCTION: Neurogenic thoracic outlet syndromes (TOS) are dominated by the nonspecific forms. This study focuses only on the rarer true forms related to proximal nerve compression in the thoracic outlet, with the presence of motor (atrophy of the hand's intrinsic muscles) and/or sensory (hypoesthesia in the territory of the medial antebrachial cutaneous nerve) deficits. The objectives of this study were to define the clinical characteristics, anatomical causes and surgical results of this condition. PATIENTS AND METHODS: Single-center retrospective study of 53 consecutive cases in 50 patients with an objective clinical deficit confirmed by nerve conduction studies. The population consisted of 47 adults and 3 children, 9 males and 41 females, with a mean age of 39 years (9-80 years), diagnosed between July 1994 and December 2019. An objective motor deficit was present in 50 cases, with the remaining 3 having a sensory deficit only. Forty cases underwent surgery, most often via the supraclavicular approach, while 13 cases did not undergo surgery because their deficit was longstanding and non-progressive. RESULTS: One operated patient was lost in follow-up. An analysis of the medical records of 18 cases, including 15 operated cases found complete recovery in 4 cases, significant improvement in 9 cases and small improvement in 2 cases at a mean follow-up of 53 months (1-162 months). Thirty-four cases were reviewed in person, including 24 operated cases and evaluated with a mean follow-up of 135 months (36-284 months): the pain had disappeared in 21 cases, thenar atrophy persisted in 17 cases, which was associated with a claw-hand deformity in 3 cases, while 2 cases had an isolated claw-hand deformity. The patients were very satisfied with the procedure in 15 cases and satisfied in 9 cases. They evaluated the benefit of surgery at 87% and their upper limb function increased from 38% (10-60%) preoperatively to 77% (60-100%) at the review. CONCLUSION: Few studies in the literature have focused on true neurogenic TOS cases. The treatment is surgical in progressive cases; an anatomical anomaly is always present. Surgical treatment eliminates the pain and helps to stabilize or even partially resolve the deficit. Despite a moderate objective gain, the patients' feeling of functional improvement is important with a high satisfaction rate. LEVEL OF EVIDENCE: IV, retrospective.

Neurolysis of the distal segment of the long thoracic nerve for the treatment of scapular winging due to serratus anterior palsy: a continuous series of 73 cases.

BACKGROUND: Serratus anterior (SA) palsy following mechanical injury to the long thoracic nerve (LTN) is the most common cause of scapular winging. This study aimed to identify the factors influencing the outcome of neurolysis of the distal segment of the LTN. We hypothesized that poor results are due to duration before surgery and to persistent scapulothoracic dysfunction. METHODS: A retrospective study was conducted. The inclusion criteria were partial or complete isolated noniatrogenic SA paralysis of at least 4-month duration with preoperative electrophysiologic assessment confirming the neurogenic origin without signs of reinnervation. RESULTS: Seventy-three patients were assessed at 45 days, 6 months, and 24 months after neurolysis of the distal segment of the LTN. At the last follow-up, improvement was excellent in 38 (52%), good in 22 cases (30%), moderate in 6 (8%), and poor in 7 (10%). No patient showed deterioration in outcomes since the beginning of follow-up. Scapular winging was no longer present in 46 cases (63%), while it was minimal in 23 (31.5%). In 4 cases (5.5%), winging was similar to the preoperative condition. DISCUSSION: The best outcomes occurred in patients who presented without compensatory muscle pain and who were treated within 12 months of paralysis. Beyond this time frame, neurolysis can still provide useful functional improvement and avoid palliative surgery. CONCLUSION: Neurolysis of the distal segment of the LTN is a safe and reliable procedure. This technique allows treatment of SA muscle palsy and corrects scapular winging with excellent or good outcomes in 82% of cases.

The Homodigital Propeller Flap: A New Tool for Fingertip Reconstruction. Surgical Technique, Anatomical Study, and Clinical Relevance.

BACKGROUND: An ideal flap for fingertip injuries should cover a significant loss of substance and avoid joint flexion to prevent later contracture and joint stiffness. In this study, the authors describe a modified homodigital island flap-the homodigital propeller flap-to better meet these requirements. METHODS: An anatomical model of fingertip loss is used to analyze the advancement achieved without flexion of the finger. Twenty-four fresh-frozen fingers were dissected. Wires were inserted to maintain joints in extension. The skin paddle was similar in location to a homodigital island flap. The neurovascular bundle was dissected without exceeding the proximal interphalangeal joint and was released from the proximal half of the paddle. Then, the homodigital propeller flap was rotated 180 degrees to cover the defect. A mixture of India ink and barium sulfate was injected into the pedicle artery after the release of the proximal half of the flap from the neurovascular pedicle to assess residual flap vascularization. India ink highlights the residual subcutaneous vascularization network of the cutaneous paddle. A radiographic study of the flap was then performed to visualize the subcutaneous vascular network of the cutaneous paddle. RESULTS: The homodigital propeller flap achieved an average cutaneous advancement of 18 mm (range, 15 to 22 mm) and allowed full coverage of cutaneous defects for all fingers while maintaining the proximal interphalangeal joint in strict extension. CONCLUSIONS: The homodigital propeller flap is a refinement of the classic homodigital island flap. It allows efficient coverage of fingertip defects because of a large advancement without flexion of the finger, reducing the risk of stiffness.

Hydroxyapatite deposits of the hand and wrist: a diagnosis not to be ignored.

Hydroxyapatite crystal deposition disease (HADD) of the hand and wrist is rare but can cause acute inflammatory syndromes that mimic infectious arthritis. These symptoms, which rapidly resolve with systemic anti-inflammatory drugs, are a source of diagnostic errors and inappropriate treatment. It is of crucial importance to make the diagnosis in order to avoid iatrogenic surgical management. The aim of this study was to determine the clinical and radiographic signs and the key features on which diagnosis depends. Treatment effectiveness and the course of the disease were also examined. Between 1992 and 2008, 12 patients consulted for an isolated acute local inflammatory syndrome of the hand or wrist, which was accompanied by a unique radiographic picture of calcific density. All patients were reassessed clinically and radiographically with a minimum follow-up of 2 years. All patients had presented with acute local inflammatory syndromes. Nine patients had edema and 8 had swelling and erythema. No patient had fever. The course was favorable in 11 patients and one patient required surgery. No patient had a recurrence at the mean final follow-up of 90 ± 64 months. The symptoms associated with hydroxyapatite crystal deposits suggest septic arthritis with acute joint inflammation. The radiological appearance is characteristic and corrects the diagnosis. Oral anti-inflammatory treatment gives more rapid spontaneous improvement, with complete and long-lasting resolution.

Comparison of subjective outcomes of Darrach and Sauvé-Kapandji procedures at a minimum 2 years' follow-up.

INTRODUCTION: In distal radioulnar joint pathology, the literature regularly recommends reserving the Sauvé-Kapandji (SK) procedure to young patients and heavy manual workers, and the Darrach (D) procedure to older patients and rheumatic wrists. However, the SK procedure is more technically demanding and requires more proximal resection of the ulna, with greater risk of instability in the ulnar stump. The aim of the present study was to determine whether the SK procedure really does show superiority. HYPOTHESIS: Subjective results are no better after the SK than the D procedure. MATERIAL AND METHODS: Seventy of the 101 operated cases (70 patients: 40 female, 30 male; mean age at surgery, 50.2 years [range, 16.4-87.2 years]) were assessed, at a minimum 24 months. Group D comprised 44 wrists, and group SK 26. Assessment was conducted by telephone interview for pain, ranges of flexion-extension and pronation-supination, strength, stump stability and satisfaction, and by mail for the QuickDASH questionnaire. Mean follow-up was 8.2 years (range, 25 months to 17 years). RESULTS: The surgical revision rate was significantly higher in SK (p=0.003). Results were comparable between groups for pain, strength, range of motion and satisfaction. Mean QuickDASH score was 45.5 in group D and 26.5 in group SK. Age-matched comparison found no significant differences on endpoints. DISCUSSION: Subjective results after the SK procedure showed no superiority over the D procedure, despite group D patients having twice the rate of heavy manual work and sport activities. This non-difference casts doubt on the need to reserve the D procedure to elderly patients and the SK procedure to young patients and heavy manual workers, especially as the latter is more technically demanding and is associated with a higher rate of surgical revision. LEVEL OF EVIDENCE: IV; retrospective study.

Ulna shortening osteotomy for ulnar impaction syndrome: Impact of distal radioulnar joint morphology on clinical outcome.

INTRODUCTION: Treatment of ulnar impaction syndrome (UIS) is based on ulnocarpal decompression, which may be achieved by ulna shortening osteotomy. The aim is to restore zero or negative ulnar variance. Tolat et al. described 3 distal radioulnar joint (DRUJ) morphologic types: vertical, oblique and reverse. Joint type has been thought to influence the clinical result of shortening, especially in the reverse type. HYPOTHESIS: DRUJ type does not influence clinical results in ulna shortening osteotomy. MATERIAL AND METHODS: Twenty-nine wrists were operated on in 27 patients: 13 female, 14 male; mean age at surgery, 43 years (range, 18-72 years). In 20 cases, UIS was idiopathic and in 7 post-traumatic. Mean preoperative ulnar variance was 3.6mm (range, 2-18mm). The osteotomy was fixed by screwed plate. RESULTS: Twenty-five patients (27 wrists) were assessed at a mean 64 months (range, 18 months to 13 years). There were no cases of infection or hematoma. DRUJ was type 1 (vertical) in 6 cases (22%), type 2 (oblique) in 14 (52%) and type 3 (reverse) in 7 (26%). Mean postoperative pain score on VAS was 0.7/10 (range, 0-4); 9 wrists remained painful. Mean Quick-DASH was 16.9 (range, 0-48) and mean PRWE 21.9 (range, 16.9-59). Thirteen patients were very satisfied, 11 satisfied, 1 moderately satisfied, and 2 dissatisfied. Mean postoperative ulnar variance was -0.1mm (range, -4 to +8mm). Three wrists developed osteoarthritis, all following traumatic UIS. There were no significant correlations between DRUJ type and other clinical or radiological parameters. DISCUSSION: Ulna shortening osteotomy has proven efficacy in UIS. The literature reports excellent or good results in 75% of cases. In the present study, 96% of patients considered themselves cured or improved by surgery, and none reported worsening. Ulna shortening osteotomy can be used in all 3 DRUJ types; DRUJ coronal morphology does not impact clinical result. LEVEL OF EVIDENCE: IV-retrospective study.

Surgical treatment of chronic instability of the metacarpophalangeal finger joint based on the intraoperative condition of the collateral ligament: Results of a single-center study with 7years' follow-up.

BACKGROUND: Severe traumatic injuries to the collateral ligaments of the metacarpophalangeal (MCP) joints of the fingers are rare and often missed. There is no consensus on how to treat neglected, chronic, and symptomatic ligament tears. The two main options are ligament reinsertion and ligament reconstruction, but no criteria exist to help surgeons choose between them. HYPOTHESIS: The structure and intraoperative appearance of the collateral ligament can be used to select between reattachment and ligament reconstruction; when the ligament is repairable, effective reattachment with a suture anchor is possible in chronic forms more than 3months after the injury event. PATIENTS AND METHODS: Thirteen patients (14 consecutive cases) who underwent surgical treatment for a traumatic complete symptomatic tear of an MCP joint collateral ligament that was at least 3months old were included retrospectively. Six patients (7 fingers) had been treated by anchor reinsertion (group A) and seven patients (7 fingers) by ligament reconstruction as described by Hsieh (group B). Clinical and radiographic assessment consisted of the QuickDASH questionnaire, measurements of strength and active range of motion of the MCP compared to the other hand, and AP and lateral radiographs over the MCP joint. RESULTS: Twelve patients (13 fingers) were reviewed after a mean follow-up of 84±49months. The mean QuickDASH was 4.7±5.4 for group A and 23.8±16.0 for group B (p=0.008). There was a significant decrease in the flexion/extension motion (64°/-6°) in group B relative to the healthy contralateral hand and group A fingers (p=0.012 and p=0.014). There were no visible degenerative joint lesions at the final assessment; however, three patients in group B had undergone revision surgery to address chronic pain. Two of them had a preoperative volar subluxation that was not corrected by the ligament reconstruction. DISCUSSION: When a ligament is determined to be repairable based on intraoperative findings, reinsertion on bone provides satisfactory and long-lasting stabilization of the MCP joint even if the procedure is not done immediately after the injury occurs. If it is not repairable and no preoperative volar subluxation is found, the ligament reconstruction technique described by Hsieh restores stability to the MCP joint in the medium term with no signs of degeneration. LEVEL OF EVIDENCE: IV; case series.

Median nerve entrapment syndrome in the elbow and proximal forearm. Anatomic causes and results for a 55-case surgical series at a mean 7years' follow-up.

BACKGROUND: Proximal median nerve (MN) neuropathy represents 1% of upper-limb compressive neuropathies. The literature reports two clinical presentations, depending on the location of the entrapment: pronator teres (PT), and anterior interosseous nerve (AIN) syndrome. HYPOTHESIS: There is no correlation between symptoms and location of proximal compressive structures on the MN trunk or AIN. PATIENTS AND METHODS: Clinical and paraclinical data from 55 surgical MN releases around the elbow and proximal forearm were analyzed retrospectively. Mean age at diagnosis was 56±15years. Preoperative sensory and motor deficit signs were present in 89% of cases. Reduced MN conduction velocity and/or neurogenic anomalies in the MN territory were present in 94% of cases. Intraoperative details of compressive structures were collected. Patients were followed up in consultation to assess progression of symptoms and deficits. RESULTS: Mean follow-up was 84±70months. Objective motor deficit signs persisted in 18 of the 35 patients (18 cases), and objective sensory signs in 19 cases. A compressive anatomical structure was systematically found. There were at least two MN entrapment sites in 13 cases (24%). No isolated AIN entrapment was found. There was a significant correlation between symptom duration and persistence of objective sensory signs (p=0.002). DISCUSSION: There was no correlation between entrapment site and clinical signs on examination. Surgery requires exploring all potential entrapment sites. Improvement may be incomplete in case of late treatment. LEVEL OF EVIDENCE: IV; retrospective study.

Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy.

Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures.

BACKGROUND: Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain. PURPOSE/HYPOTHESIS: The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders. RESULTS: Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment. CONCLUSION: The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

Epidemiological, clinical and histological features of adipose tumors in the hand and wrist: Findings from a continuous series of 37 cases.

INTRODUCTION: Adipose tumors are the most common soft tissue tumor in adults; however, their epidemiology and histology in the hand and wrist are not well-defined. The aim of this study was to describe the histology and treatment strategy for this type of tumor at a specialized cancer center. HYPOTHESIS: The frequency of these tumors is underestimated, and their histology signature varies. MATERIALS AND METHODS: The clinical and paraclinical data of adults treated for an adipose tumor lesion in the hand or wrist were analyzed retrospectively: age, clinical history, time elapsed between discovery and treatment, type of treatment. The dimensions, location and histology of the tumor were collected. The patients were contacted to inquire about persistent symptoms and sequelae. RESULTS: Thirty-seven tumors (37 patients) were included between January 2003 and December 2018, thus making up 7.5% of all the soft tissue tumors in the hand or wrist. The mean patient age was 59years (28-84years). Except for one fortuitous discovery, the tumors were discovered because the patient had an unusual lump. The lump was associated with distal paresthesia in six cases. The mean time to treatment was 47.5months (1-240months). The lesion was a conventional lipoma (31 cases) or one of its benign variants (6 cases). The mean size was 3.76cm in the long axis (1-11.5cm) and the mean weight was 9.8g (3-60g). The mean follow-up was 73.5months (2-177months). Tumors in the fingers were smaller and lighter than those in the wrist (p=0.004 and p=0.034). DISCUSSION: The prevalence of adipose tumors is underestimated within hand and wrist tumors. The most common way these tumors are discovered is due to compressive neuropathy with paresthesia and/or dysesthesia. While these tumors are nearly always benign, this does not justify ignoring the opinion of the multidisciplinary tumor board or underestimating the small possibility of the lesion being a liposarcoma. LEVEL OF EVIDENCE: IV, retrospective, single-center study.

Immediate self-rehabilitation after open Latarjet procedures enables recovery of preoperative shoulder mobility at 3 months.

PURPOSE: To evaluate short-term clinical outcomes of shoulders treated for anterior instability by open Latarjet procedures (OLP) followed by immediate self-rehabilitation. The hypothesis was that patients would recover preoperative function at 3 months with no adverse events related to self-rehabilitation. METHODS: The authors retrieved clinical and radiographic records of 307 consecutive shoulders treated by the same surgeon for anterior instability by OLP with immediate self-rehabilitation. Four shoulders did not meet eligibility criteria and 38 were lost to follow-up, leaving a study cohort of 265 shoulders. Patients performed self-rehabilitation exercises at home from the first postoperative day. Follow-ups at 1 and 3 months evaluated recurrence of instability, postoperative complications, pain, active forward elevation (AFE), passive forward elevation (PFE), external rotation (ER) and internal rotation (IR). RESULTS: The difference between mobility before surgery and at 3 months was 0° for AFE, 0° for PFE, 10° for ER, and 0 spine segments for IR. Thirteen shoulders (5%) which had not followed the self-rehabilitation protocol during the first month had significantly more pain and less improvements in mobility (p < 0.05). Multivariable analyses revealed that patients who adhered to self-rehabilitation in the first month had greater improvements of AFE, PFE, and IR (p < 0.05). CONCLUSIONS: Immediate self-rehabilitation after open Latarjet procedures enabled recovery of preoperative shoulder mobility at 3 months. Patients who did not adhere to immediate self-rehabilitation had more pain and less improvement in mobility. Furthermore, immediate self-rehabilitation was found to be independently associated with better recovery and did not cause any adverse events. LEVEL OF EVIDENCE: Level IV.

The "Double Lasso-Loop" Technique Used for Arthroscopic Proximal Biceps Tenodesis.

Disorders of the long head biceps tendon are among the most challenging of shoulder problems to diagnose and manage. In this Technical Note, we introduce an arthroscopic technique for proximal biceps tenodesis high in the groove at the articular margin of the humeral head using a single anchor and 2 self-cinching loops followed by 5 alternating half-hitches to secure the construct. This method is simple and enables stable fixation of the biceps tendon.

Free fillet lower leg flap for coverage after hemipelvectomy or hip disarticulation.

INTRODUCTION: Tumor resection is the gold standard treatment for soft tissue and bone sarcomas. In the pelvis, this may require a hemipelvectomy that can compromise primary skin closure. Flaps are essential in this context; however the vascularization of potential pedicled flaps may have been removed during tumor excision. Using healthy tissue from the amputated limb as a free flap is an excellent coverage option. HYPOTHESIS: The free fillet flap from an amputated lower limb is a simple and reliable coverage technique after hemipelvectomy or hip disarticulation. MATERIAL AND METHODS: Seven patients were operated on at three specialty centers: six transpelvic amputations (external hemipelvectomy) and one hip disarticulation. In three cases, the flap consisted of the superficial posterior compartment of the calf area and in the three other cases, the lower leg compartments with the fibula and its intact periosteum. Complications were documented. RESULTS: Clear resection margins were achieved in all patients. The mean follow-up at the final visit was 13 months (range, 6.5 to 21 months). Six patients had complications but only one resulted in loss of the flap. Four patients were able to be fitted with a hip prosthesis. DISCUSSION: The free fillet flap from an amputated lower limb is a reliable coverage technique (86%) after hemipelvectomy or hip disarticulation. In the 16 cases previously reported in the literature, there were no wound-healing failures. Local flaps are often too fragile with insufficient muscular padding. This free flap is the preferred first-line technique as it spares other potential free flaps in case of failure without increasing the morbidity of a procedure that is already extensive. This coverage technique should be one the options considered after external hemipelvectomy. LEVEL OF EVIDENCE: IV, retrospective study.